Harnessing the Power of Relationships:
Applying Systems Approaches to Improve
Family Planning Use
Susan Igras & Rebecka Lundgren
Institute for Reproductive Health,
Georgetown University
PRESENTATION ROAD MAP
1. Gender and Family Planning Challenges
2. Response: Systems-oriented Interventions
3. Pilot Implementation Experience
4. Results - Pilot Effectiveness
5. Preliminary Results - Scale-up
6. Conclusion
GENDER AND FAMILY
PLANNING CHALLENGES
SOCIO-ECOLOGICAL MODEL
Macroenvironment
Enabling youth to live
gender-equitable lives free
of violence, coerced sex,
and unintended
pregnancy
Enabling all ages to forge
healthy sexual relationships
and make informed
choices regarding child
spacing and limiting
Institutional
Community
Interpersonal
lndividual
NEGOTIATING SOCIAL SYSTEMS
UGANDA & BENIN PILOT INTERVENTIONS
1. What aspects were considered in designing
systems interventions using social diffusion to foster
gender equality and FP outcomes?
2. Can such interventions be designed for scale?
3. What were pilot study results and implications for
systems-focused interventions?
INTERVENTION DESIGN
Systematic
use of social
network
principles
Targeted to
address
different life
stages
Shift social
norms/
attitudes to
foster more
equitable
behaviors
Gender
synchronized
Designed for
scale: low
cost, simple,
minimal
training
Diffuse new
ideas and
info through
community
levels
Iterative use
of evidence
to develop,
refine &
implement
package
THE GREAT PROJECT - GENDER ROLES,
EQUALITY AND TRANSFORMATION
PARTNERS
 Institute for Reproductive Health,
Georgetown University
 Pathfinder International
 Save the Children
GOAL: Improve gender equality and
reproductive health outcomes in Northern
Uganda
GREAT: GENDER & LIFE COURSE
INTERVENTION PACKAGE
1
COMMUNITY
ACTION CYCLE
2
RADIO
DRAMA
3
VHT SERVICE
LINKAGES
GOAL:
4
COMMUNITY GROUPS
USING TOOLKIT
“Growing
Up GREAT”
Flipbooks
Activity
Cards
Community Radio
Game Discussion
Guides
Boys and girls aged 10-19 form equitable gender norms and
adopt attitudes and behaviors which positively influence
health outcomes and reduce gender-based violence
TÉKPONON JIKUAGOU
PARTNERS
 Institute for Reproductive
Health, Georgetown
University
 CARE Benin
 Plan International
GOAL: Reduce unmet need by
addressing social barriers that
stop women and men from
acting on their desires to space
or limit births
WHY A SOCIAL NETWORK APPROACH?

SOCIAL LEARNING
SOCIAL INFLUENCE
Network members exchange
ideas and information; and
evaluate the relative benefits
of innovation
 Network members follow norms
of gatekeepers to gain
approval and avoid conflict
DIFFUSION
10%
of women shared knowledge or
positive experiences with FP use
with friends or family (baseline)
TÉKPONON JIKUAGOU SOCIAL
NETWORK INTERVENTION PACKAGE
1
ENGAGE COMMUNITIES
IN SOCIAL MAPPING
4
LINK FP PROVIDERS
WITH INFLUENTIAL
GROUPS
2
SUPPORT INFLUENTIAL
GROUPS IN REFLECTIVE
DIALOGUE
5
USE RADIO TO CREATE
AN ENABLING
ENVIRONMENT
ENCOURAGE
3 INFLUENTIAL INDIVIDUALS
TO ACT
GOAL:
Women and men with unmet need for for family
planning receive via their social networks new ways of
thinking and acting
COMPARATIVE SUMMARY
GREAT in Uganda
Tékponon Jikuagou in Benin
 Youth 10-19 at important life
moments
 People of reproductive age
in union
 School clubs, community
leaders and groups
 Socially-influential network
actors – groups and
individuals
 Radio broadcasts
 Links to health services
 Multi-channel social diffusion: influence and comparison by
women and men (not gender and FP facts)
PILOT IMPLEMENTATION
WHAT IS A “LEAN” COMMUNITY-BASED
SOCIAL-CHANGE INTERVENTION?
 Work with existing community
resources, e.g., groups and
opinion –leaders
 Easy- to-use, low-cost materials
 Minimal orientation and
supervising/coaching
 Does not require highly skilled,
heavily trained change agents
 Diffusion through radio
SYSTEMATIC REALITY-CHECKS ON:
GENDER EQUITY, EASE OF USE, &
COMMUNITY ACCEPTABILITY
Reflection
Participatory
review cycles with
research &
implementation
staff
Our challenge:
to keep it simple
and scalable
Action
Awareness and
Understanding
RESULTS – PILOT EFFECTIVENESS
METHODS AND OUTCOME
MEASURES
Quasi-experimental
Base and endline surveys
in intervention and control
groups
Stratified 2-stage cluster
samples
Uganda: 4,500 women
and men
Benin: 2,160 women and
men
• Perceived social norms and
support for family planning
• Perceived access to services
• Couple communication
• Contraceptive use
ENABLING ENVIRONMENT
Improving youth outcomes requires adults
to support more equitable attitudes and
behaviors
50
%
Not Exposed
vs
61
%
Exposed
PROVIDE ADVICE TO ADOLESCENTS
(ADULTS)
GENDER EQUALITY
Improved gender-equitable attitudes,
and changes in behaviors
37%
Not Exposed
vs
48%
Exposed
BELIEVE MEN AND WOMEN ARE EQUAL
(OLDER ADOLESCENTS)
FAMILY PLANNING BEHAVIOR
NEWLY MARRIED / NEW PARENTS
Effect
Size (%)
Confidence
Interval
Communication with partner
about FP use in last 3 months
12
(0.1, 22.9)
FP seeking behavior
16
(7.0, 25.1)
Current FP use
10
(1.1, 19.6)
ENABLING ENVIRONMENT
IF I BELIEVE THAT MY
NETWORK…
Discusses FP
Approves of FP
Uses FP
…THE ODDS THAT I WILL USE FP
INCREASE GREATLY
2.7 
1.3 
odds (2.05-3.50)***
odds (1.00-1.65)*
3.4 
2.0 
odds (2.54-4.45)***
odds (1.51-2.53)***
4.0 
2.5 
odds (3.04-5.13)***
odds (1.91-3.26)***
Adjusted for age, education, religion, number of children, number of co-wives; P-values: * p<.05; ** p<.01; *** p<.001
FAMILY PLANNING BEHAVIOR
EXPOSURE TO GROUP DISCUSSIONS AND INFLUENTIALS INFLUENCED COUPLE
COMMUNICATION ABOUT FP
TALKS TO PARTNER ABOUT
WHICH METHOD TO USE
TALKS TO PARTNER ABOUT
HOW TO OBTAIN A METHOD
2.5  1.8 
2.7  1.9 
odds (2.00-3.16)***
odds (2.17-3.46)***
odds (1.47-2.20)***
odds (1.56-2.37)***
Adjusted for age, education, religion, number of children, number of co-wives; P-values: * p<.05; ** p<.01; *** p<.001
FAMILY PLANNING BEHAVIOR
EXPOSURE TO THE PACKAGE INFLUENCED FP METHOD USE & MET NEED
USES A METHOD
1.5 
1.1
odds (1.17-1.97)**
odds (.894-1.49)
MET NEED
1.5  1.2 
odds (1.19-2.00)**
odds (1.02-1.57)*
Adjusted for age, education, religion, number of children, number of co-wives; P-values: * p<.05; ** p<.01; *** p<.001
PRELIMINARY RESULTS:
SCALE UP
OVERLAPPING PHASES,
NOT DISCRETE STEPS…
WE ARE HERE
SCALE UP GOALS DEFINED:
FIRST WAVE EXPANSION
Tékponon
Jikuagou
GREAT
GEOGRAPHIC
EXPANSION
INSTITUTIONALIZATION
•
20+ new CBOs
•
•
2 new Districts (full package)
2 additional Districts (VHT only) •
•
Government/CBOs able to
continue activities without
resource team
•
•
•
•
Included in policy documents,
budget, and implementation
plans
•
Absorbed into district/sub
county structures
4 new development projects3 NGOs
4 Health Zones, 88 villages
NGOs and projects have
capacity to implement
without resource team
IN DISCUSSION: Included as
high impact practice in MOH
CONCLUSION
ENGAGING THE BROADER SOCIAL CONTEXT
TO IMPROVE FAMILY PLANNING USE
 Multi-layered social interaction approaches
can positively affect social determinants of FP
use
 gender norms
 family and peer support
 couple communication
 Systems-based strategies can foster
community engagement in implementation
and expansion
DESIGNING INTERVENTIONS WITH
A FOCUS ON SCALE
 Design lean interventions
 Develop scale-up capacity/mind set among staff
 Be vigilant to scale-up feasibility through review
of pilot data and learning discussions
 Provide actionable data at regular intervals for
course-corrections
ADDITIONAL SUPPORTS FOR NORMATIVE
INTERVENTIONS GOING TO SCALE
 Clarify values and engagement in social norm
interventions among staff
 Develop check-ins and reflection as part of
package; one-off staff training may not be sufficient
to internalize social norm intervention processes and
aims
 Monitor intervention properties - community
acceptability and intervention ‘stickiness’
THANK
YOU
www.irh.org/projects/GREAT_Project
www.irh.org/projects/tekponon_jikuagou/
 INGO and NNGO in-country
networks (project, partners)
 Peace Corps
 Spontaneous adoption &
expansion
 Regional INGO networks
 Government program-bilateral
programs – inside and outside
of health